Implementation Science Principles Shape Scalable Early Therapy for Infants at Risk of Motor Delay

It takes an average of 17 years for new healthcare evidence to make its way into routine clinical care, and nearly 70 percent of efforts to change practice fall short of full implementation. For infants at risk of neuromotor delay, where early intervention matters most, that lag can shape a child’s entire developmental trajectory. A team of researchers and clinicians in Chicago argues that the solution lies not in producing more evidence, but in designing trials so that the results are ready for real-world adoption from the moment they are generated.

In a perspective article published in Frontiers in Rehabilitation Sciences on 28 October 2026, researchers from Shirley Ryan AbilityLab, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, and Pathways.org describe how they embedded implementation science principles into the design of an ongoing clinical trial. The trial, known as Project CORB, is a multisite longitudinal randomized controlled trial that begins in the neonatal intensive care unit and follows infants to 12 months’ corrected age. Its goal is to create an evidence-based, easily scalable early physical therapy intervention for infants at risk of neuromotor delay.

The intervention rests on a framework called CARES, which stands for Caregiver engagement, Active leaRning, Environmental enrichment, and Strengths-based. The framework was developed through an extensive literature review, expert consensus, and stakeholder feedback to establish best practices for optimizing infant neuromotor health during the first year of life. It is a transdiagnostic, relational-health model that positions caregivers as equal partners in their child’s care and emphasizes infant-directed action as the primary mechanism of change, departing from traditional impairment-focused, clinician-directed therapy. The study team later added a fifth principle: high dosage, meaning two 60-minute therapy sessions per week, which is notably higher than standard-of-care early intervention, which often begins after 3 months’ corrected age and averages 45 minutes weekly.

High dosage is only useful if families can actually sustain it. The researchers therefore applied implementation science strategies to reduce logistical burden. Physical therapy sessions are delivered primarily in person, either at the NICU bedside or in the family’s home, with telehealth offered as a secondary option so that services continue rather than being canceled during illness or unforeseen circumstances. Caregivers are encouraged to weave home activities into the infant’s daily routine in small intervals rather than blocked practice, and activities are divided into caregiver-led and infant-led formats within structured environments to maximize opportunities for active learning throughout the day.

Resource development followed a deliberately pragmatic path. Rather than building materials from scratch, the team partnered with Pathways.org, which over the last 40 years has created structured play activities called games with guidance from 45 expert pediatric clinicians and developmental specialists, presented as short online videos. To adapt these materials, three expert clinicians established developmental blocks tied to distinct therapeutic goals focused on tasks and functional movements that promote the infant’s independence in natural environments, rather than milestone-based achievements. Interventions that restricted infant-directed movement, such as orthotics, adaptive equipment, strictly passive techniques like stretching or massage, and positioning aides, were excluded.

The vetting process was extensive. A panel of two physical therapists and an instructional designer reviewed 683 video clips, of which 559 were original to Pathways.org and 124 were newly recorded by the study team. Games not focused on gross motor development were excluded, and those misaligned with key principles or of poor video quality were marked for revision or removal. After an initial review, a panel of eight pediatric physical therapists with an average of 25 years of NICU experience evaluated all materials and provided feedback on revisions, user experience, and accessibility. In the end, 266 video clips were included and compiled into an Activity Playbook of 184 videos up to one minute in length, each with written text, narration, closed captioning, and depictions of caregivers and babies, spanning development from birth to one year and tailored for both NICU and home settings.

Maintaining rigor required standardized training and systematic fidelity monitoring. Five study team members wrote two manuals, one for the NICU phase and one for the home phase through 12 months’ corrected age, each containing background information, key principle definitions, documentation requirements, and therapy session guides. Content experts and then practicing clinicians reviewed the manuals. All physical therapists were required to pass a written examination to establish implementation reliability, and every month their sessions were video-recorded and scored by at least two independent reviewers. If a session fell below 85 percent adherence on any key principle, the therapist was retrained and reevaluated, creating regular accountability and objective, reproducible assessment rather than reliance on self-report.

To illustrate feasibility, the authors present a case example from a randomly selected participant whose data will be excluded from the trial’s overall results. The infant was born at 34 weeks of gestation, weighed 1,790 grams, and had risk factors for neuromotor delay including a left grade III intraventricular hemorrhage and cystic periventricular leukomalacia. Enrolled at 37 weeks’ postmenstrual age and randomized to the experimental intervention group, she received an average of 1.90 therapy sessions per week over 51.7 weeks, with 94.9 percent of sessions delivered in person at home. Four caregivers logged a total of 34,860 home activity minutes, averaging 674.7 minutes per week, guided by 73 unique Activity Playbook videos. Seven fidelity monitoring sessions showed an average adherence of 96.3 percent to the intervention principles.

The case participant’s motor function improved from 3 to 12 months’ corrected age. At 3, 6, and 9 months, a subset of assessments, including the General Movements Assessment Motor Optimality Score-Revised, Hammersmith Infant Neurological Examination asymmetry scores, and high-resolution inertial sensors, indicated potential neuromotor delay, with limb asymmetry as a key concern. By 12 months’ corrected age, the participant showed no clinically significant limb asymmetry and performed within age-expected limits on all administered assessments. Caregivers reported high engagement, hope and optimism, perceived appropriateness of the plan, and a collaborative relationship with the physical therapist, though time commitment, fatigue, illness, and scheduling acted as barriers at times. A separate focus group of seven caregivers participating in the trial also reported positive feedback on intervention feasibility and educational resources.

The authors are careful to note that Project CORB is still ongoing, with final assessments scheduled for December 2026, so the trial’s overall results remain unknown. If the intervention proves efficacious, they express high confidence that it can be smoothly implemented into clinical practice by trained clinicians and caregivers, particularly since Pathways.org offers its games free for public use on its website and mobile application. They frame their approach of dosage support, resource adaptation, standardized training, and fidelity monitoring as a replicable method for narrowing the research-practice gap, while acknowledging that future research must evaluate system-level factors such as training, staffing, costs, sustainability, and translation to practice.

Subject of Research: Application of implementation science principles to design a scalable early physical therapy intervention for infants at risk of neuromotor delay

Article Title: Bridging the research–practice gap in infant neuromotor development by harnessing principles from implementation science

Article References: Carey, S., Hoffman, E., Patrick, C., Hunter, J., Babula, S., Clark, E., O’Brien, M. K., Pouppirt, N., deRegnier, R.-A., Lieber, R. L., & Jayaraman, A. (2026). Bridging the research–practice gap in infant neuromotor development by harnessing principles from implementation science. Frontiers in Rehabilitation Sciences, 7, 1985679. https://doi.org/10.3389/fresc.2026.1985679

Image Credits: AI Generated

DOI: 10.3389/fresc.2026.1985679

Keywords: implementation science, infant neuromotor development, early intervention, physical therapy, Project CORB, research-practice gap, NICU, caregiver engagement, fidelity monitoring, clinical trial design, pediatric rehabilitation, CARES framework